Kathryn Oakes Senior Nurse for Viral Hepatitis Kings ... · Microsoft PowerPoint - LJWG Showreel...
Transcript of Kathryn Oakes Senior Nurse for Viral Hepatitis Kings ... · Microsoft PowerPoint - LJWG Showreel...
Kathryn OakesSenior Nurse for Viral Hepatitis
Kings College HospitalNovember 2011
� Background to the AVT outreach project
� Referring into the service and the role of the Physical Health Harm Reduction Nurse (PHHRN)
� Milestones
� Referral, assessment and treatment data
� Substance misuse levels
� Barriers to project success
� HCV - 85% chronicity rate with 20% cirrhosis rate1 and 3-5% risk per annum HCC2
� HCV most common cause transplantation in western population3 – 40% transplants at KCH = 168 pa
� Mortality rate planned to triple by 20304 with an £8 billion economic burden to the NHS5
� HCV prevalence in IDU’s up to 66% in London6
� Population reluctant to attend secondary care7
� LHH 1000 to 1200 clients with 10-15 new p.w1. Alter MJ Semin Liver Dis 1995; 15:Management of Hepatitis C NIH Consensus Statement 1997; March 24-26:15(3). 2. Cabrera R, Nelson D R. (2009) Review article: the management of
hepatocellular carcinoma. Alimentary Pharmacology and Therapeutics, 31: 461-476. 3. Lodato et al. (2008) Clinical trial: peg-interferon alfa-2b and ribavirin for the treatment of genotype-1 hepatitis C
recurrence after liver transplantation. Alimentary Pharmacology and Therapeutics, 28: 450-457 4. Cheruvu et al. (2007) Strategies to control hepatitis C infection among injection drug users. Hot
Topics in Viral Hepatitis, 6: 23-30. 5. British Liver Trust. (2010) Facts about Liver disease (online). 6. Health Protection Agency. (2009) Shooting up. Infections among injecting drug users in the United Kingdom 2008: An update. 7. Foster G. (2008) Injecting drug users with chronic hepatitis C: should they be offered antiviral therapy? Addiction, 103: 1412-1413
1
� Kosh Agarwal, Lead Consultant for VHS, KCH
� Mike Kelleher, Clinical lead for LA
� Kathryn Oakes, Senior Nurse VHS, KCH
� Mick Collins, Borough Lead for LA
� Tony Docherty, Deputy borough Lead for LA
� Mags O’Sullivan, Kristen Stone – PHHRN and Integrated Care Nurses, VHS KCH
� Martin McCusker, service user
� Dee Cunniffe, Reckitt Benckiser
� Fenella Jolly, Team Leader BBV/Homeless Team
� Alcohol intake does not exceed 40 units weekly
� Ideally no IV Crack Cocaine
� Client agrees to regularly attend appointments and consents to appropriate drug screening
� Stable housing with fridge
� Agree to enter needle exchange programme
� Stable from a psychological perspective
Is Client stable ? Assessment of client stability re: addiction
issues
Referral to Hepatitis Team
Appointment for
screening and education with Hep
CNS within 14 days
Client not
suitable for
AVT
Client
suitable for
AVT
Hepatology
review
Delivery AVT16 to
72 weeks
Cirrhotic or HBV offer Follow up at
Kings
Referral back to
Drug/alcohol advisory service
Contact Hep CNS team for
advice
Yes
No
Client tests Positive HCV/HBV
REFERRAL PATHWAY
� Contact known HCV RNA positive clients
� BBV testing and HBV vaccination
� Work with the substance misuse teams to identify clients for treatment and co-ordinate referral into the service
� Engagement of clients, education and harm reduction advice
� Acts as a resource and contact for patients on treatment and attends all KCH appointments
� Strategic role in service development
Working group established
Operational Policy and SLA finalised
Initial appt PHHRN
Transfer of PHHRN post
Meet service users
First treatment clinic
PHHRN appointed
1st assessment/education clinic
First medical clinic
Action plan formulated
Jan 2009 June 2010 Feb 2011 May 2011 July2011 Sept 2011
� RAISING AWARENESS & EDUCATION
ReferralSource Number patients Referred to Kings
Keyworkers at LHH 89 26 (29%)
FenellaJolly 2 1 (50%)
DRR 4 0 (0%)
RIOTT at MH 8 8 (100%)
Triage 15 0 (0%)
Previous bloods (Fenella) 9 1 (11%)
WHD + keyworker 3 2 (66%)
WHD 3 1 (33%)
Relative 1 0 (0%)
Total 133 * 39
•* 81 known HCV, 52 tested – 25 HCV RNA pos and 26 tested RNA negative, 1 HCV ab pos on
DBST and refusing venous sample•Data collection period 29/06/2011 to 26/10/2011
39 Booked for assessment and education
with KCH viral hepatitis CNS team
1 removed –
unfavourable
genotype and
IL28
16 booked for
future
assessments
17 completed
assessment
3 DNA’d& 1
declined
assessment
1 assessment
delayed –
social issues
Genotype Disease stage
Patient Genotype Treatment week Response
One 1 non cirrhotic 9 Complete EVRTW9
Two 1a non cirrhotic 14 RVR
Three 1b cirrhotic 0 N/A
Four 3a non cirrhotic 19 Complete EVRTW9
Five 3 cirrhotic 5 RVR
Six 3a non cirrhotic 14 RVR
Seven 3 non cirrhotic 5 5 log drop at TW4 to 9.92 E1
IU/Ml
Eight 3 non cirrhotic 5 3 log drop at TW4 to 1.06 E2
IU/Ml
Nine 3 non cirrhotic 3 N/A
%
Alcohol Number Abstinent Substitute Drug Level of drug use Number Substitute
Units p.w drugs Prescribing use Prescribing
0 26 15 (3 OT) 3 RIOTT 11 Cannabis 3 1 RIOTT
1 No substitutes Heroin or crack smoked once a week 4 (3 OT) 10 substitute
11 substitute IV heroin once or twice a week 1 (1 OT)
IV heroin once to three times a week 1 (1 OT)
IV heroin two to four times a week 2
0 - 20 8 4 2 RIOTT 4 Cannabis 1
2 substitute Occasional speed 1 (1 OT)
Heroin or crack smoked once a week 1
IV heroin use and crack smoked 1 - 2
wk 2
20-40 4 3 1 RIOTT 1 Cannabis and smoking crack 1 RIOTT
2 substitute
60 1 0 1
Heroin/IV skin popping 3 times a
week 1 1 substitute
Total 39 22 17
� Lack of awareness amongst substance misuse population; concerns about the side effects; previous experiences in secondary care; chaotic lifestyles – competing priorities
� Resource and time needed for engagement, education and referral
� Working across two sites; IT, medication dispensing, transportation samples, honorary contracts
� Different cultures and organisational changes
� Project is a work in progress
� We have learnt a lot about this population and working across sites/specialities
� To date a model that integrates specialist viral hepatitis and addiction services appears to work well
� Treatment outcomes will give us more insight into the effectiveness of the model
� The role of the PHHRN has been essential to engage clients and bridge services